Common Oral Mucosal Diseases

Wen-Chen Wang, DDS, MS, Ph.D

Assistant professor of Dept. of Oral Pathology, Faculty of Dentistry, College of
Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Head of Dental Dept., Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
E-mail: wcwang@kmu.edu.tw

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 Oral mucosa

MUCOUS MEMBRANE
Definition:
-Moist lining of the intestinal tract, nasal passages
and other body cavities that communicate with the
exterior
Oral mucosa:

Oral mucous membrane

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Ref: Antonio Nanci: Ten Cates Oral Histology, Development, structure, and function 6th ed
 Oral mucosa
STRUCTURE OF ORAL
MUCOSA
B.V.
N.
--Similar to skin
Epithelium
..epidermis
* Epithelial ridges, rete pegs
Lamina propria...
..dermis
Submucosa...
..subcutaneous
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Ref: BJ Orban:Orbans oral histology and embryology,9th ed.
 Oral mucosa

FUNCTIONAL CLASSIFICATION
OF ORAL MUCOSA
Keratinized areas
Masticatory mucosa
hard palate & gingiva
vermilion border

Nonkeratinized areas
Lining or reflecting mucosa
lip, cheek, alveolar mucosa, vestibular fornix,
mouth floor, soft palate, ventrum of tongue
Specialized mucosa
dorsum of tongue

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 Oral mucosa

FUNCTIONS OF ORAL MUCOSA

Protection
Sensation

Secretion

Thermal regulation

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METHODS OF ORAL DIAGNOSIS

History taking
Inspection
Oral examination
-Palpation
-Percussion
-Aspiration,
-Auscultation
Radiographic examination
Laboratory examination Wen-Chen Wang
 History Taking
What, where, when, how
Chief complaints
Present illness
Past medical history
Family history
Social history
Occupational history
Dental history
Review of symptoms by system
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 Chief Complaints
Pain Bad taste
Soreness Halitosis

Burning sensation Parthesia and anesthesia

Bleeding Recent occlusal problem

Loose teeth Too much saliva

Dry mouth Delayed tooth eruption

Swelling

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 Onset and Courses
1. Masses increase in size just before
eating
ex. salivary retention phenomena,
sialolithiasis

2. Slow-growing masses (duration of

months to years)
1) Reactive hyperplasia
2) Chronic infection
3) Cysts
4) Benign tumors Wen-Chen Wang
3. Moderately rapid-growing masses
(weeks to about 2 months)
1) Chronic infection
2) Cysts
3) Malignant tumors

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4. Rapidly growing masses (hrs to days)
1) Abscess (painful)
2) Infected cyst (painful)
3) Aneurysm
4) Salivary retention phenomena
5) Hematomas

5. Masses with accompanying fever

1) Infections
2) lymphoma, leukemia
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 Inspection

Location
Contours

Color

Surfaces

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Contours
Normal & variation

Color
Masticatory mucosa vs lining
mucosa
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 Color
Normal: pinkish

Whitish Epithelial hyperplasia, Hyperkeratosis

or dense collagen bundle
Reddishatrophic epitheliumvessels dilatation
or hyperplasia
Blackishnevus, tattoo, melanosis
Yellowish: adipose tissue, glands
Translucent blue reflection of liquid

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Leukoplakia
Hemangioma

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Peutz-Jeghers syndrome
Fordyces granule
Mucocele
Betel nut chewers mucosa
 Surfaces

Normal
smooth & glistening, except dorsal
tongue, rugae & attached gingiva

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 Pathologic Mass May Be--
1) Smooth surface
-arises beneath epi, originates from
mesenchyme
ex : benign & early maligant salivary gland tumors,
benign & malig. mesenchymal T.
( fibroma, osteoma, hemangioma,
myoma), cellulitis, mucocele

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irritation fibroma

MixedWen
tumor
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2) Rough surface
-except due to
trauma, infection
and maligancy,
originates in the
epithelium
ex: papilloma, VH
V.ca, ulcerative &
exophytic SCC
Ref: NK wood, PW Goaz: Differential diagnosis of oral and maxillofacial lesions 5th ed

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3) Sessile or pedunculate

Pyogenic granuloma
 Palpation
--A third eye of clinical examination
Anatomic regions & planes involved
Mobility
Extent
Consistency
Painless, tender or painful
Unilateral or bilateral
Solitary or multiple

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Anatomic Regions & Planes Involved

Locates a firm mass, superficial or deep

Difficult if swelling or painful

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 Mobility
1. free movable
2. fixed to skin but not to the
underlying tissue
3. free movable to the skin but
fixed to the underlying tissue

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4. bound to both skin or mucosa
and to the underlying tissue
1) fibrosis-after a previous inflammation.
2) malignant- from skin or mucosa invade
to underlying tissue
3) malignant- from deeper tissue invade to
surface epithelium
4) malignant- from loose CT to both the
superficial & the deeper layers
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 Extent

Whether a mass has well defined,

M-D or P-D borders will depend
on :
-Border of the mass
-Consistency of surrounding tissue
-Thickness of overlying tissue
-Sturdiness of underlying tissue
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 Consistency
Fluctuation & emptiability: Fluid contented
lesion
Soft: vein, loose CT, glandular tissue
Cheesy: sebaceous cyst, epidermoid cyst
Rubbery: relaxed muscle, glandular tissue
with capsule, arteries
Firm: fibrous tissue, tensed muscle, large
nerve
Bony hard: bone, cartilage, tooth structure

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Torus palatini

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Painless, Tender or Painful

Pain
1.inflammation-- mechanical trauma or
infection
2.painful tumors--some neural tumors
3.sensory nerve encroachment
Tenderness
Low-grade inflammation & internal
pressure, chronic infection
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 Unilateral or bilateral

Solitary or multiple

Solitary : A local benign or early

malignancy
Multiple : Systemic, disseminated
diseases or syndrome

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Erosive Lichen planus

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 Special Examination

Radiographic exam
Aspiration, smear cytological
exam., biopsy
Laboratory exam

(Suggested by attending drs.)

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Common Oral Mucosal
Diseases

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 Ulcerative Lesions

Ulcerepithelium loss caused by any

reason
Trauma, burn, infection, oral cancer
Most of traumatic ulcers would be healed
within 2 weeks spontaneously, otherwise,
a further evaluation should be necessary.

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 Traumatic Ulcer
A definite trauma history and clinical
features can be traced
Usually occur at the soft tissue regions

which can be bitted or hit by teeth , ex.

Lower lip, tongue and buccal area
Ill-fitted dentures

Improper oral habits, ex,

lip biting, tongue biting etc.

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A traumatic ulcer of the author
 Burn
Chemicals or drugs, thermal
Suicide, psychiatric problems,

Placement an aspirin tablet in oral to relieve

toothache
Phenol, H2O2, NaHOCl used in dental practice

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 Recurrent Aphthous Ulcer

Commonest oral mucosal disease

Herpetiform RAU Wen-Chen Wang

Patients Can Be Grossly Classified
As :
1.Primary immune dysregulation
-genetic, stress, congenital or acquired
immunal disease (leukopenia, AIDS, endocrine
etc. )
2.Decreased mucosal barrier
-Trauma, blood diseases, nutritional
defficiency(Vit.B12follic acid, iron)
3. Increased antigenic expose
-Bacteria, virus, etc.
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 Treatment of RAU

Topical steroid or NSAID therapy, local

cauterization
Underline diseases or any possible
etiology should be evaluated if suffered
severely and recurred very often

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 Tuberculosis (TB)

Worldwide, chronic infectious disease,

airborne droplets
Crowded or unsanitary environment
Opportunity infection, 5-10% progress
into active disease
Immunocompromised patients, ex. DM,
HIV infection
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 Oral Tuberculosis
Primary and secondary
Exposure to infected sputum or
hematogeneous spread
Indurated, chronic painless ulcer
Enlarged regional lymph nodes

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 Herpes Simplex Virus
Infection (HSV type 1)
Airborne droplets or direct contact
Primary and recurrent
Most primary HSV infections are
asymptomatic, some suffered from
primary herpetic gingivostomatitis
Usually in children and young adults

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Clinical Characters of HSV Infection
Primary-upper respiratory tract infection
oral symptomssmall vesicles/tiny
ulcers Latency
Secondary- reactivation of latent virus
after trauma, menstruation, systemic
upsets, etc.

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 Secondary HSV Infection

A discrete collection of vesicular

swellings rupture erosion crusted
The commonest recurrent lesion is herpes
labialis.
Attached gingiva, hard palate
Heal within 1-2 weeks without scarring

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Recurrent HSV infection

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Oral White Lesions and Betel
Nut Related Lesions

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 Lichen Planus

Reticular type (lace-like network of white lines,

Wickhams striae)
Erosive type
Asymptomatic or burning irritation in reticular type,
symptomatic in erosive type
Middle-aged, F:M=3:2
Idiopathic, stress
Topical or systemic steroid therapy
Malignant potential is controversial
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Lichen planus
 Oral Candidiasis

Oral normal flora

Local irritation ill-fitting or improper
denture hygiene
Antibiotics
Immuno-compromised, systemic disease
patients
Complete denture of upper jaw

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 Oral Candidiasis

Oral manifestation:
Pseudomembranous type--creamy white
Atrophytic type-- reddish
Symptoms: varied, from mild to burning
sensation, pain and dysphagia

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Oral candidiasis
Oral Cancer and Precancerous Lesions
-Related to Betel Quid Chewing Habits

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 What is
oral cancer?

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 Oral Cancer is-

Any cancer found in oral cavity

A cancer of the oral epithelial

origin, ex. squamous cell
carcinoma, verrucous carcinoma

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 Who is in high risk ?

Contributing
factors of oral
cancer?

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 Contributing Factors
of Oral Cancer
--In betel nut (betel quid) consumption areas
Betel nut chewing habit ( 80% in Taiwan)

Others are:

1. smoking 2. alcoholism
3. radiation exposure 4. improper nutrition
5. syphilis 6. candidiasis
7. mutation of gene 8. immunodeficiency
9. improper denture
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 Oral Cancer

Early: may be a leukoplakia or

erythroplakia
Tumor cells invade into connective
tissue or grow exophytically
Clinical features: reddish or whitish
ulcerative surfaces with induration,
delayed healing process

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 Oral Cancer

Locations:
In Taiwan : buccal mucosa is the most

common, followed by lateral border of

tongue, retromolar, lower lip, palate and
gingiva

In the world: lateral border of tongue is

the most common
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Oral Cancer

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Oral Cancer

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Visit your dentist as soon as
possible if any oral ulcer
doesnt heal within 2 weeks !

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 What are
Oral Precancerous Lesions ?

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Oral Precancerous Lesions

Leukoplakia
Erythroleukoplakia

Erythroplakia

Oral submucous fibrosis

Verrucous hyperplasia

Erosive lichen planus*

*precancerous condition
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 Leukoplakia
White lesions which cannot be characterized by lichen
planus, oral candidosis etc.
Malignant change 4~5%
Homogeneous leukoplakia and non-homogeneous
leukoplakia

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Erythroleukoplakia

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 Verrucous Hyperplasia

Exophytic, papillary or
cauliflower-like
appearance

White, or pink to
reddish, resulted from
varied keratosis

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 Oral Submucous Fibrosis
(OSF)
20-40 y/o, male
Sites: oral mucosa, oropharynx, esophagus
Clinical characteristics:
-Dense collagen bundles, decreased vascularity,
epithelium atrophy, whitening of the mucosa
-Trismus
-Epithelium atrophy decreased protection,
sensitive to spicy foods

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Oral submucous fibrosis

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Oral submucous fibrosis

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 Managements of OSF

Mouth opening exercise

Local cortical steroid injection
Surgical treatment combined with skin
graft

Prognosis is not good in the severe OSF

patients

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 Oral Manifestations
of Systemic Diseases

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Burning Mouth Syndrome
(BMS)
Bacterial or fungal infection
Dry mouth
Nutritional abnormality
Anemia
Endocrine disturbance, DM
Improper denture
Idiopathic

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 Clinical Features of BMS

Middle aged female or elder male

Burning sensation, esp. tongue and
tongue tip; taste change
Normal appearance and color
Diagnosis and treatment depend on
the etiology
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 Vitamin Deficiency

Vit. A: keratosis
Vit. B: glossitis, angular cheilitis,
burning mouth
Vit. C: generalized gingival swelling,
bleeding tendency and ulcers,
periodontitis

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 Vit. B12 deficiency

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After treatment
 Blood Diseases
Anemia
pale mucosa
Hemophilia

hematoma or petechiae
Coagulation problems
associated with impaired liver function

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 Leukemia

Bleeding tendency
Idiopathic oral ulcers, necrotic gingival
margin
Gingival swelling (chloroma)
Oral candidosis

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Go for an oral and
dental examination
every 6 months!

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 Kaohsiung Medical University
References
1. Antonio Nanci: Ten Cates Oral Histology,
Development, structure, and function 6th ed.
2. BJ Orban:Orbans oral histology and
embryology,9th ed.
3. NK wood, PW Goaz: Differential diagnosis of oral
and maxillofacial lesions 5th ed.
4. BW Neville, DD Damm, CM Allen,JE Bouquot: Oral &
Maxillofacial pathology. 2nd ed.

Acknowledgement
Clinical pictures were fully supported by Dept. of
Oral Pathology, Kaohsinug Medical University
http://www.kmu.edu.tw/media/photos/001.jpg

Wen-Chen Wang